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Indicates required fields
If a required field does not pertain to you then please enter
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into the field so that the form will submit.
Applicant Information:
*
Type of Membership:
Resident
Non-Resident
Young Professional
Also check if applicable:
Business Affiliation
Non-Resident Lobbyist
*
Applicant's first name
*
Applicant's middle initial
*
Applicant's last name
*
Date of birth
(Format MM/DD/YYYY)
*
Residence address line 1
Residence address line 2
*
City
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State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
*
ZIP
*
Residence phone with area code
*
Residence Email
*
Place of employment
*
Title
*
Business address line 1
Business address line 2
*
City
*
State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
*
ZIP
*
Business phone with area code
Fax
*
Email
*
Community Involvement
Volunteer Commitments
Education
University
Degree Earned
Graduate School
Degree Earned
Military: branch, highest rank attained, dates of active service
Elected Offices: dates, city, county, state or national office
*
Primary Profession and/or Business Category (check all that apply)
Accounting/CPA
Engineering
Lobbying
Advertising
Government
Real Estate
Architect
Health/Medicine
Religious
Banking
Insurance
Retail
Communications
Investments
Retired
Computers
Journalism
Utilities
Construction
Judicial
Other:
Education
Law
Topics of Interest (check all that apply)
Art
Musical Entertainment
Trips
Cultural Events/Exhibits
Reciprocal Clubs
Shopping
Sporting Events
Bridge/Cards
Speakers Topics
Business Discussion
Spirits
Cigars
Sports
Baseball
Basketball
Golf
Platform Tennis
Tennis
Other
Computers
Adult Cooking Classes
Other:
Kids Cooking Classes
Gourmet Dinners
Literary Discussions
Spouse Information:
*
Spouse's name
Date of birth
(Format MM/DD/YYYY)
Place of employment
Title
Business address line 1
Business address line 2
City
State
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
ZIP
Business phone with area code
Fax
Email
Community Involvement
Volunteer Commitments
Education
University
Degree Earned
Graduate School
Degree Earned
Military: branch, highest rank attained, dates of active service
Elected Offices: dates, city, county, state or national office
Children Information:
Names & birth dates of children
I prefer to receive correspondence from the Sangamo Club at the following locations:
*
Emailed
Syllabus
Newsletter:
Residence Email
Business Email
*
Billing:
Online
Home Address
Business Address
*
Name of Sponsoring Member:
*
NOMINEE: I agree that checking this box and forwarding this application acts as my signature on this application. I certify that all the information provided is true and correct. If elected to Membership, I agree to be bound by the by-laws, rules and regulations of the Sangamo Club now in effect or hereafter adopted.
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